Provider Demographics
NPI:1568526705
Name:MARIE, ALEX J (LP)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:J
Last Name:MARIE
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 CLEVELAND AVE S
Mailing Address - Street 2:SUITE 217
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-3858
Mailing Address - Country:US
Mailing Address - Phone:952-250-7549
Mailing Address - Fax:651-698-0712
Practice Address - Street 1:790 CLEVELAND AVE S
Practice Address - Street 2:SUITE 217
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55116-3858
Practice Address - Country:US
Practice Address - Phone:952-250-7549
Practice Address - Fax:651-698-0712
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4525103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN710717000Medicaid
MN710717000Medicaid